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Full text of "Modern antiseptic surgery and the role of experiment in its discovery and development"

FELLOW'S PAMPHLETS 



MODERN ANTISEPTIC SURGERY 



AND THE ROLE OF EXPERIMENT IN ITS DISCOVERY 
AND DEVELOPMENT 



^Y. W. KEEN, M.D., LL.D. 

PHILADELPHIA 



DEFENSE OF RESEARCH 
PAMPHLET XII 

Issued by the Council on Defense of Medical Research 
of the American Medical Association 



"The humanity which would prevent human suffering is a 
deeper and truer humanity than the humanity which would save 
pain or death to animals." — Charles W. Eliot. 



CHICAGO 

American Medical Association 

Five Hundred and Thirty-Five North Dearborn Street 

1913 



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AMERICAN MEDICAL ASSOCIATION 

53S NORTH DEARBORN STREET, CHICAGO 



MODERN ANTISEPTIC SURGERY 



And the Role of Experiment in Its Discovery and 
Development 



W. W. KEEN, M.D., LL.D. 

PHILADELPHIA 



/ — 



Digitized by the Internet Archive 
in 2012 with funding from 
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MODEBN ANTISEPTIC SUKGERY 

AND THE ROLE OF EXPERIMENT IN ITS DISCOVERY AND 
DEVELOPMENT 



W. W. KEEN, M.D., LL.D. 

PHILADELPHIA 



The subject naturally divides itself into three parts: 
(1) the conditions before the introduction of the anti- 
septic method by Lister; (2) the means by which his 
system was discovered and developed, and (3) the con- 
ditions existing after the introduction of the method, 
i. e., at the present time. 

My surgical life covers all three of these periods since 
I graduated in medicine in 1862, some years before Lis- 
ter began his work. I have, therefore, fought my way 
from the horrors of the preantiseptic days up to the 
delights of the present antiseptic days. 1 

I. THE PREANTISEPTIC PERIOD 

In my early surgical experience every accidental 
wound and every surgical operation (that is, an inten- 
tional wound) was followed by inflammation and sup- 
puration, i. e., the discharge of "pus" or "matter." This 
was not only constantly expected as an unavoidable 
process of Nature and believed to be needful for healing, 
but was constantly realized. Hence the pus was called 
"laudable" pus ! How well I remember forty years ago 
at the beginning of each winter's session when I was the 
assistant of the late Professor Samuel D. Gross, his turn- 
ing to the orderly and saying to him, "To-morrow, 
Hugh, I shall lecture on suppuration. Go over to the 
hospital in the morning and get a cupful of pus for my 
lecture." Pus, mark you, was always "on tap," so to 
speak, though the little hospital contained only a dozen 
beds ! 

1. In this article I use the word antiseptic as the more popular 
one to include also the aseptic method. 



Perhaps the best way to give the reader an idea of 
wound conditions at that time will be to describe an 
ordinary operation and. its results. We will suppose that 
it is an amputation. The surgeon approached the opera- 
tion with the clean hands of a gentleman. He usually 
wore an old coat covered with dried blood spots from 
previous service. His finger-nails very likely were long 
and no special attention was given to them. The instru- 
ments were taken out of a velvet-lined case and were 
as clean as ordinary table-knives would be. The opera- 
tion was done without any preliminary cleansing of the 
skin other than to remove any visible dirt. If the knife 
happened to fall on the floor it was picked up, rinsed in 
a basin of ordinary water and used as it was. The 
marine sponges then always used were washed clean in 
ordinary water and used over and over again even after 
being saturated with foul pus. The blood-vessels were 
tied with ordinary silk ; one end was cut short, the other 
one hung out of the wound. After an amputation of a 
fleshy thigh I have often seen 25 or 30 such "ligatures," 
as they are called, gathered into two bundles, one at each 
end of the wound. The flaps were then sewed together 
with an ordinary needle and thread and the stump 
dressed first with an old rag (which, however, would be 
ordinarily clean) or scraped lint spread with some sim- 
ple grease. Over that would be placed some other rags, 
lint, cotton, or other dressing, and .finally a bandage. 
During the Civil War these greasy dressings gave place 
to simple cold-water dressings. 

By the second day the patient would begin to have 
considerable fever. By the third or fourth the tempera- 
ture would rise to what we now know (for medical ther- 
mometers were not in general use in that early day!) to 
about 103, 104 or 105 F. Then we would poultice the 
wound. Every few hours the patient would be disturbed, 
a new poultice put on to replace the old one, now cold, 
i'oul and ill-smelling, and by this time bathed with pus. 
T have often seen the pus escaping by the tablespoon- 
ful and the wounds alive with squirming maggots 
resembling chestnut worms. By this time also it was 
hoped that the silk ligatures, with which the arteries 
had been tied, had literally "rotted" loose and each one 
of them was gently pulled on to the discomfort of the 
patient. Care was taken that the ligatures with knots 
tied on them (in order to distinguish those that secured 
the large blood-vessels) should not be pulled on severely 



until probably the tenth or twelfth day. Meantime the 
patient was tossing about the bed with pain, with thirst, 
without appetite, without, sleep except such as morphin 
would secure. This at the same time dried up all the 
secretions, producing constipation and other evils. 

By about the tenth to the fourteenth day, suppura- 
tion having been fully established and quantities of pus 
pouring from the wound, the fever would subside and 
the wound would begin slowly to heal. Of course, the 
healing could not be complete so long as the silk liga- 
tures were still protruding from the wound. Sometimes 
they did not become detached for even months or years, 
but more commonly all of them would rot loose in from 
ten days to three weeks. When the silk ligatures on the 
large blood-vessels came away, if the healing process 
had formed in the blood-vessels a firm clot, which had 
become adherent, and, so to speak, "corked" it up, all 
went well. But, as very frequently happened, when the 
ligature and the rotten end of the artery were pulled off 
and there was no clot to act as a stopper, "secondary 2 
hemorrhage" followed. This often came on after the 
patient's wound had been dressed and the surgeon had 
left, and, if so, very likely the first notice that the nurse 
had that anything was wrong would either be the gasping 
for breath of the patient or his moans and cries, or some- 
times by the blood which had not only saturated the mat- 
tress, but had even appeared in a pool on the floor. 
How fatal were such hemorrhages may be seen from the 
fact that in* 2,235 cases of hemorrhage in the Civil War 
61.7 per cent, of the patients died. 3 

I shall never forget one night about ten days after the 
battle of Gettysburg, when it was my business as "officer 
of the day" to attend to all emergency cases. That night 
I was called to five cases of secondary hemorrhage. To 
indicate what a difference there is between modern and 
ancient conditions, in the thirty-four years since October, 
1876, when I began the practice of the antiseptic 
method, I have not seen as many cases of secondary 
hemorrhage as I treated in that one night. 

It was a rare thing for any patient after such an oper- 
ation to get well under three or four weeks, and it was 
not uncommon for healing to be delayed for three or 

2. So called to distinguish it from "primary hemorrhage," 

i. e. the bleeding occurring at time of the accident or operation. 

3. Med. and Surg. Hist. War of the Rebellion, Part 3, Surg. 
Vol., p. 765. 



6 

four months, so that, in spite of the great mortality, the 
wards of the hospitals were cumbered with convalescent 
patients. The rare case in which healing took place by 
"first intention/' i. e., at once, was recounted as a tri- 
umph. To-day it is precisely the reverse. The case in 
which healing does not occur primarily and at once is 
regarded as a disaster. 

But a prolonged convalescence was the least of the 
evils to which a patient was subject. A large majority 
of the wounds were followed by erysipelas, by lockjaw, 
or by blood poisoning, and hospital gangrene sometimes 
became a veritable plague. Gangrene in various forms 
during the Civil War was rife and often fatal. In 2,503 
cases 1,1*42 patients died, a mortality of 45.6 per cent. 4 
In one variety which was frequent, hospital gangrene, a 
simple flesh wound scarcely larger than the bullet which 
made it, became larger and larger till a hand would 
scarcely cover it and it would eat into the tissues until 
one could put half his fist into the sloughing cavity. 

Of 505 cases of lockjaw (tetanus), 451 were fatal, a 
mortality of 89.3 per cent. 5 Pyemia or blood poisoning 
was terribly frequent and almost as fatal as it was fre- 
quent, for of 2,818 cases in the Civil War 2,747 patients 
died, or 97.4 per cent ! 6 When a joint was opened or 
wounded, the result was frequently either amputation 
or death, or not uncommonly amputation and. death. 
Of 2,382 wounds of the knee-joint alone for which 
amputation was performed 1,212 patients died, a mor- 
tality of 51 per cent., and of 973 similar wounds for 
which amputation was not performed 591, or 61 per cent, 
of the patients died. 7 

Fractures, as most people know, are divided into two 
kinds: simple fractures in which the skin is unbroken, 
and compound fractures in which the broken bone pro- 
trudes through the skin. Simple fractures nearly always 
heal with relatively little pain and slight fever; but in 
the preantiseptic days when the skin was broken and the 
bone protruded two out of three patients with these 
compound fractures were sure to die. 

Moreover, certain regions of the body were forbidden 
ground unless the surgeon were absolutely compelled to 
invade them. "No one would open the head if he could 

4. Ibid., p. 824. 

5. Ibid., p. 819. 

6. Ibid., p. 858. 

7. Ibid., p. 367. 



possibly avoid it. No one would dare to make an inci- 
sion through the abdominal wall into the cavity of the 
abdomen unless a bullet or a dirk had gone before him 
and opened the way. The reason for our hesitation was 
that death stalked behind us. 

How eloquent is the statement of Sir Samuel Wilks, 8 
that "the change came home to me in an almost 
startling manner from what I witnessed in the post- 
mortem room. Some time before [i. e., before Lister's 
discoveries], when reading a paper on pyemia (blood 
poisoning), I had no difficulty in collecting 100 cases 
which had occurred within a very short time previously, 
when suddenly this terrible malady disappeared — it was 
gone never to return." So, too, lockjaw (tetanus), 
except in accidental cuts that have been neglected and 
have not received proper surgical care, has almost com- 
pletely disappeared. Again, at the present day one prac- 
tically never sees erysipelas after operations; and in 
order to find illustrations of hospital gangrene to show 
to my classes for the last thirty years I have had to rely 
on pictures from the Surgical History of the Civil War 
and other similar sources, for I have not seen a single 
case in private or hospital practice since I first adopted 
the antiseptic method in 1876. 

II. THE DISCOVERY AND DEVELOPMENT OF THE 
ANTISEPTIC METHOD 9 

Neither time nor space will allow me to describe the 
many earlier steps. Schwann, in 1837, in studying 
putrefaction, reached the conclusion that it was not the 
gases of the air, especially the oxygen, as was then uni- 
versally believed, that caused putrefaction, but organic 
particles which floated in the air and which could be 
destroyed by heat. In 1854 Schroder and Dusch showed 
that putrefaction did not occur in organic fluids in 
flasks if the air entering the flasks was simply filtered 
through cotton wool. Pasteur, in 1864, showed that it 
was necessary neither to heat the air nor thus to filter it, 
for if the air merely entered through a tortuous tube in 
which the dust could settle before it reached the fluid 

8. Royal Com. on Vivisection, 1907-08. Q. 7.750. 

9. See Lord Lister's Collected Papers, Oxford, 1909 (later ref- 
erence to these Collected Papers will be indicated simply by "Lister, 
vol. — , p. — )," Brit. Med. Jour., Dec. 13, 1902. The Lister number 
celebrating the fiftieth anniversary of his receiving his degree, and 
Lister's Huxley Lecture in the same journal, Oct. 6, 1900, and 
Cameron's "Lister and the Evolution of Wound Treatment, etc.," 
Glasgow, 1907. 



no change took place in the fluid, or if flasks containing 
a material which would putrefy were left open in a place 
where the air had been undisturbed sufficiently long to 
allow the dust to settle, as, for example, in a cellar, no 
decomposition took place and no growth appeared in 
such fluids. 

Lister naturally was profoundly impressed by these 
studies of Pasteur and he proceeded to make many 
experiments to confirm or disprove them. Among them 
I will only relate the following: 10 Lister filled four 
glass flasks one-third full of urine and drew out the 
neck of each flask with a spirit lamp into a tube less than 
one-twelfth of an inch in diameter. Three of these long 
open tubes were then bent at various angles downward, 
while the fourth, equally narrow, was left short and ver- 
tical. Each flask was then boiled for five minutes, after 
which they were left with the ends of the small necks 
still open. Through these open mouths the air. 
including its ox} r gen, would pass out during the heat 
of the day and pass in during the colder night. The 
boiling was to kill any organisms in the liquid or 
on the sides of the glass. The object of the bending 
of the three necks downward was to allow the air to 
pass in and out, but to intercept the particles of 
dust, which, according to the germ theory, caused 
putrefaction. The germs, being heavier than air, could 
not rise in the bent necks. The fourth neck, however, 
being short and vertical, not only allowed the air to pass 
in and out, but gave a very narrow but real opportunity 
for dust and germs to fall into the liquid. If any of 
these were living organisms they could produce putrefac- 
tion. In a short time the vessel with the short and ver- 
tical neck showed growths of mold and the liquid 
changed its color, showing chemical changes; but in the 
three flasks with bent necks the urine after four years 
icas entirely unaltered. A year after the commencement 
of the experiment a little of the urine in one of the flasks 
with a bent neck was poured into a wine-glass ; it had not 
lost its original acidity and normal odor and a micro- 
scope showed not the minutest organism. In two days 
it was most offensive, and under the microscope already 
teemed with organisms. The other three flasks were 
subjected to a further severe and rather amusing test. 
Two years after the beginning of the experiment Lister 

10. Lister: ii, 173; Brit. Med. Jour., 1871, ii, 225. 



9 

had to transport them from Glasgow to Edinburgh on 
the railway when he was appointed to the chair of sur- 
gery in Edinburgh. He took charge of these flasks him- 
self, "nursing them carefully/' as he says, "to the amuse- 
ment of my fellow travelers." In the drive from the 
station to his house the violent rocking of the carriage 
churned up the contents of the flasks till the upper part 
was full of a frothy mixture of this proved putrescible 
liquid with the atmospheric gases; yet after two years 
more no decomposition had taken place. 

The explanation of this convincing experiment was 
simply this : The germs in the atmosphere could not 
rise against gravity in any of these tubes bent downward 
and so could not gain access to the urine. This easily 
preserved a decomposable fluid for four years, although 
the air passed in and out freely every day. But the 
urine in the flask with the straight but very narrow neck 
in a few days had undergone decomposition. The only 
difference between the flasks was that the three bent 
tubes prevented the entrance of the germs, though not of 
oxygen or other constituent of the air, while the straight 
but equally narrow tube allowed the germs to enter 
through in very small quantities, and yet these few grew 
and produced putrefaction. 

In order still further to confirm this experiment, 
however, Lister tested these bent tubes by the condensed 
beam of light which Tyndall had used and found that 
they were optically empty. 11 

These experiments convinced him that it was not the 
oxygen or any other gas in the air that caused inflam- 
mation and suppuration, but that these were caused b} r 
the minute organisms suspended in the air. In dressing 
a wound, then, the problem was how to exclude not the 
air or its oxygen, which was impossible, but how to 
exclude the organisms in the air. This could be done 
by applying a dressing saturated with some material 
capable of destroying the life of these germs. This was- 
the basis of the antiseptic method. 12 It must be remem- 
bered that at that time we were wholly ignorant of what 
now everybody knows, that there are hundreds of differ- 
ent kinds of germs or bacteria. Even the greatest scien- 
tists were then groping in the dark seeking for the light 
by observation and especially by experiment. 

11. See Tyndall's charming lecture on Dust and Disease, in Frag- 
ments of Science, 1871, p. 275. Appleton & Co. 

12. Lister: ii, 37; Brit. Med. Jour., 1867, ii, 246. 



10 

About that time Lister was much struck with an 
account of the effect of mingling phenol (carbolic acid) 
with the sewage of the town of Carlisle, England. 13 He 
proceeded, therefore, to experiment with it in compound 
fractures. I have already stated how fatal a compound 
fracture was in those days. Indeed, Mr. Syme, the great 
Edinburgh surgeon, predecessor and father-in-law of 
Lister, was inclined to think that, on the whole, "it 
would be better if in every case of compound frac- 
ture of the leg amputation were done without any 
attempt to save the limb." The marked success which 
followed his dressing these compound fractures 13, 14 
with carbolic acid led him then to experiment with its 
use in abscesses. 13 - 14 > 15 This was followed again by such 
remarkable success that he was led to try it in accidental 
wounds and finally to intentional and extensive wounds, 
i. e., surgical operations. 16 

Practically the progressive introduction of the anti- 
septic system from compound fractures up to deliberate 
surgical operations was one vast experiment in the 
human living body — an experiment justified, as all the 
world well knows, by its splendid and continuing results. 
Yet when in 1880 or 1881 Lister wished to make addi- 
tional experiments on animals to perfect his method still 
further, so stringent was the law in England that he was 
obliged to go to the Veterinary School at Toulouse. 
France. 17 

Like many surgeons, Lister had noticed the fact that 
a needle or a bit of glass would often lie for an indefinite 
period in the body without producing inflammation or 
pus, but that a bit of silk or linen thread was sure to 
produce pus. He believed the reason was that the 
thread was porous and that its interstices contained 
these germs which no one had then seen and identified, 
and that they gave rise to decomposition and produced 
the pus. So, Lister, from his previous experiments with 
phenol (carbolic acid), believed that if the thread with 
which an artery was tied were steeped in phenol and 
both the ends of the silk were cut short it might be left 
in the wound without producing any inflammation or 

13. Lister : ii, 3 ; Lancet, 1867. i, 326. 357. 387, 507 ; ii, 95. 

14. Lister, ii, 3, 32, 37 : Brit. Med. Jour., 1867, ii, 246. 

15. Lister, ii, 32, 36, 42 ; Brit. Med. Jour., 1867, ii, 246. 

16. Lister, ii, 188, 199, 256, etc. ; Brit. Med. Jour., 1871, ii, 225 ; 
Edinburgh Med. Jour., 1871-2, xvii, 144 ; Edinburgh Med. Jour.. 
1875-6, xxi, 193, 481. 

17. Lister, ii, 281 ; Lancet, 1881, ii, 863, 901 ; Tr. Interhat. Med. 
Cong., London, 1881, ii, 369. 



11 

suppuration. The wound could then be closed at once — 
an immense gain, for it would heal at once. "Before 
applying these principles on the human subject," he says, 
"I though it right to test them on one of the lower ani- 
mals." 18 Accordingly, Dec. 12, 1867, he tied the great 
blood-vessel in the neck of a horse, having steeped the 
silk for some time in a solution of phenol. Both ends 
were cut short, the wound was entirely sewed up and 
treated with phenol dressings. Ten days after the opera- 
tion the dressings were removed, the wound was healed, 
and there was no pus ! Thirty-nine days after the opera- 
tion he carefully examined the artery which he had tied. 
The operation was a complete success, the blood current 
had been entirely arrested and the thread had been cov- 
ered in by dense fibrous tissue. Thus encouraged, he 
says : "I felt justified in carrying a similar practice 
into human surgery.'' 19 Jan. 29, 1868, 20 he saw a 
woman, 51 years old, with an aneurism as large as a 
large orange in the upper part of the left thigh. (An 
aneurism, I should explain, is a dilated portion of an 
artery, the yielding of the wall being due to disease of 
the wall of the blood-vessel. This dilatation continues 
to increase in size till finally the wall of the artery is so 
thin that it bursts and the patient dies from hemor- 
rhage.) On the following day he tied the woman's 
artery with a piece of silk which had been steeped for 
two hours in phenol. 

The wound was treated like that in the horse's neck, 
i. e., both ends of the ligature were cut short, the wound 
again entirely closed and a phenol dressing applied. The 
patient was immediately relieved of the pain she had 
previously experienced; she had no fever, the pulse was 
practically normal the entire time, and "her appetite, 
which had been absent during the four weeks of agony 
that preceded the operation, returned two days after 
it." 21 She made a perfect recovery. November 30, ten 
months after the operation, she suddenly expired. For- 
tunately, Lister himself had the opportunity of making 
the post-mortem. He found that her death was due to 
the bursting of a similar aneurism inside of the chest. 
Examining the artery which he had tied, he found that 

18. Lister, ii, 63; Lancet, 1867, ii, 668. 

19. Lister, ii, 65 ; Lancet, 1867, ii, 668. 

20. Lister ii, 88; Lancet, 1869, i, 451. 

21. Lister, ii, 89 ; Lancet, 1869, i, 451. 



12 

the silk had almost all disappeared, but that there was a 
little fluid around the remnant of the ligature, which 
probably would have developed into a small abscess and 
might have caused great mischief had she lived longer. 
This, therefore, suggested to him the expediency of sub- 
stituting for the silk some other substance which would 
be more readily absorbed. 21 

In Philadelphia years before Dr. Physick had already 
tried animal ligatures made of buckskin, Dorsey those of 
kid, Hartshorn had used parchment, and Bellenger and 
Eve the tendon of the deer, but for various reasons these 
had all been abandoned. Lister determined to try cat- 
gut. Although he had great confidence in the use of 
catgut steeped in a solution of phenol, yet he says 22 "in 
order to put the antiseptic animal ligature to the test, 
I made the following experiment," for only by experi- 
ment in an actual living body of animal or man could 
the question whether it was actually safe or not be surely 
answered. Dec. 31, 1868, he tied the right carotid 
artery in the neck of a healthy calf at several places with 
different kinds of animal ligature, including catgut. 
All were cut short except one end of the catgut, which 
was purposely left three-quarters of an inch long to 
determine what would become of this foreign material. 
The wound was completely closed and dressed. After 
ten days the dressings were removed and the wound 
found quite dry. Thirty days after the operation Lister 
says, on dissection, he was struck with the entire absence 
of any infection or inflammatory thickening in the 
vicinity of the blood-vessel. On exposing the artery 
itself he was greatly disappointed at first to find the 
ligature to all appearance still there and as large as ever. 
On more careful examination, however, he found that 
this apparent ligature was not the catgut ligature at all, 
but that this ligature had been transformed into bands 
of living tissue, making the artery not weaker, as silk 
often did, but stronger than ever at the point where it 
was tied. The knots had disappeared and also the three- 
quarters inch of catgut purposely left. Everything had 
oeen absorbed. 

Even one not a surgeon can see what an enormous dif- 
ference in rapidity of healing without inflammation, pain 
or other serious disturbance of the body this use of cat- 
gut with immediate total closure and healing of the 

22. Lister, ii, 93 ; Lancet, 1869, i, 451. 



13 

wound provided. Before Lister, the old ligatures hang- 
ing out in bundles were always inviting infection, sup- 
puration, erysipelas, lockjaw, blood-poisoning, hospital 
gangrene and death. Xo patient was absolutely safe 
till the wound was absolutely healed and this often 
required weeks or months. With the catgut ligature, 
both ends being cut short, the wound closed at once, 
and, the ligature being absorbed, the wound healed 
in less than a week, not uncommonly in three or four 
days, with little, if any, immediate suffering and with- 
out any ultimate danger of those many serious com- 
plications above mentioned. But no one not a sur- 
geon can appreciate to the full the meaning of these 
brief words. While the patient made a smooth and 
speedy recovery without complications, the surgeon slept 
the uninterrupted sleep of the just, secure against 
wearing anxiety on account of sudden hemorrhage or 
insidious infection. The heart-breaking tragedies which 
often made the surgeon wish he were a hod-carrier ot 
even in his grave are now but specters of a horrid past. 

As I have said, we had no idea at first of the enormous 
variety and different characters of the germs. In his 
early studies on putrefaction, Lister spoke of them in a 
general way as "germs," because the various species of 
plants (for they are plants and not animalculas) had not 
been distinguished. Xow there are scores and even hun- 
dreds of known varieties. Many of these simply cause 
putrefaction or decomposition and are not in themselves 
capable of giving origin to any particular disease. Other 
varieties, each one of which causes a special disease and 
can cause no other disease, have been isolated and iden- 
tified. Some of these germs cause medical diseases, 
with which I have nothing to do here. The germs of 
lockjaw, tuberculosis, anthrax (wool sorters' disease), 
erysipelas, glanders, etc., are among the most virulent 
foes with which the surgeon has to contend. 

How have these been identified and how do we prevent 
their entrance into the system of the patient? The 
process is very simple to describe, but very complicated 
and difficult practically. Let us take the case of lock- 
jaw for instance. A peculiar kind of germ, looking a 
good deal like a tack with a straight body and a large 
head at one end. was discovered by animal experiments 
by Xicolaier in earth and dust in 1884. 23 In 1880 

23. Deutsch. med. Wchnschr., 1884, No. 52, p. 842. 



14 

Kitasato, the Japanese bacteriologist, 24 first obtained it 
in pure culture, former experimenters having failed 
because they did not know that it only grows well when 
oxygen is excluded. 

But how do we know that this tack-like germ and it 
alone is the cause of lockjaw? 

First, in a patient ill with lockjaw, this particular 
bacillus or germ must be discovered. 

Second, a pure culture of it must be produced ; that is 
to say, the tetanus bacillus must be separated from all 
other germs and cultivated by itself. Third, some of 
this pure culture of tetanus unmixed with any other 
germs whatever must be injected into an animal to see 
point-blank whether this particular bacillus will produce 
lockjaw. Fourth, from the body of this animal the same 
germ that was injected must be recovered. Fifth, with 
a pure culture of this recovered bacillus the cycle must 
be begun over again and completed sufficiently fre- 
quently to assure the experimenter that the connection 
between the disease and the germ is not accidental, but 
essential and invariable. Sixth, no other germ used in 
the same way must produce lockjaw. 

In this same manner the germs that produce inflam- 
mation and suppuration, which are the ever-present 
danger to the surgeon, have been identified, and also, 
what is equally important, the places where they and 
many others exist. In this way we have determined the 
fact that, while there are some in the air, they are few in 
number and so constitute a small though a real danger. 
But the places where they are found and are most dan- 
gerous are on the skin and clothing of the patient, the 
hands of the surgeon and especially under his finger 
nails and at the roots of his nails, on instruments, dress- 
ings, silk, catgut, and other things used for ligatures; 
in fact, practically every material that one can think of. 
We know now how all-pervading they are. We know, 
too, that phenol (carbolic acid), corrosive sublimate and 
other chemicals, or that boiling for a certain time, or 
heating to a certain degree and for a certain time, will 
kill these germs. Thousands of such painstaking 
researches in test-tubes and by many other bacteriologic 
methods have been carried out all over the world by men 
either wholly unpaid, working for the love of truth and 
love of their fellow creatures, or paid but meager pit- 

24. Deutsch. med. Wchnschr.. 1889, No. 31. 



15 

tauces. Then when a discovery seems to have been made 
comes the needful, the finally convincing, the unavoid- 
able experiment — in a living body itself. The only ques- 
tion is should Lister have made this final test first on a 
horse and a calf, or on two human beings? Can any 
one with a sane, well-balanced mind hesitate as to the 
answer ? 

III. THE RESULTS 

The results of the establishment of the antiseptic 
method have been so extraordinary as to be incredible 
were it not for ample testimony the world over. They 
have been already stated in part, but a few words more 
must be added. 

At present before an operation is begun the patient's 
skin, the surgeons' and the nurses' hands are scrupu- 
lously disinfected, sterile gloves are usually worn and 
every person is clothed in a disinfected gown. The 
instruments, dressings, ligatures, everything that is to 
come in contact with the wound, is carefully disin- 
fected. Disinfected gauze "sponges" are used once and 
then discarded. 

It is almost impossible for any one not a surgeon to 
understand how different are the results from this radi- 
cal change of methods. No change of climate from 
fierce mid-winter storms to lovely summer breezes or 
autumn golden harvest could be greater. Most wounds 
now heal within a few days, one might almost say with- 
out the patient's being sick. Compound fractures and 
opened joints heal as if there had been no break in the 
skin. Arteries can be tied anywhere without fear of 
secondary hemorrhage. The abdomen is now fearlessly 
opened. 

A woman with an ovarian tumor no longer has an 
operation postponed until it is very dangerous but 
inevitable, but by early operation is relieved almost with- 
out danger, even from tumors so large as to weigh twice 
as much as the patient herself. When I was assistant to 
Dr. Washington Atiee in the late sixties, before the anti- 
septic period, two out of three of his ovariotomy patients 
died, yet he was the then most famous operator in 
America. ISTow any surgeon who loses more than five 
out of 100 is looked at askance by his colleagues, and 
many, many hundreds of cases have been operated on 
with a mortality falling even below 1 per cent. There 
is not an organ in the abdomen that has not been 
attacked; organs which formerly when diseased could 



1G 

net be touched because death was almost sure to follow 
are now operated on every day. In fact as I once 
described it, the abdominal cavity is almost the surgeon's 
play-ground ! The stomach, the intestines, the liver, the 
gall bladder, the pancreas, the spleen, the kidney, every 
organ is operated on, and with extraordinary success. 
Did space permit, a more detailed statement could be 
given, but it could scarcely be more convincing. 

In obstetrics the same happy results have followed the 
introduction of the antiseptic method. Puerperal or 
child-bed fever, which not uncommonly used to kill one- 
half or two-thirds or even three-fourths of the women in 
the maternity wards of a hospital, now is practically 
unknown except in the neglected cases brought into the 
hospital at a late date, and the preantiseptic general 
mortality in. maternity cases has been reduced from 10 
per cent, or more to 1 per cent, and less. Brain tumors, 
abscesses and other diseases of the brain formerly inevit- 
ably caused death, for we never dared to touch them. 
ISTow the number of recoveries is very large. Compound 
fractures now have a mortality of 2 or 1 per cent, or 
less, instead of over 60 per cent, and now very rarely 
require amputation ; and amputations formerly followed 
by death in one-half the cases have a mortality of 10 per 
cent, or less. In general, both the soldier and the sailor 
are provided with the first aid packet, which contains an 
antiseptic dressing. This has enormously diminished 
the mortality of wounds received in battle. 

Perhaps no better evidence of the value of the anti- 
septic method in civil life can be adduced than the 
results in three hospitals. In Munich 25 the General 
Hospital was excessively unhealthy. Blood poisoning 
was very frequent and hospital gangrene, which had 
appeared in 1872, had become annually a more and more 
frightful scourge until 1874, when 80 per cent, of all 
wounds that occurred in the hospital, whether accidental 
or inflicted by the surgeon, were attacked by it ! At the 
beginning of 1875 Nussbaum introduced the antiseptic- 
treatment. From then on till Lister's visit, presumably 
in the summer of 1875, not one single case of hospital 
gangrene had occurred and only one case of blood poison- 
ing, and that a doubtful one. Erysipelas was rare and 
mild instead of being very prevalent and severe, and the 
convalescent wards, which formerly had been filled to 

25. Lister, ii, 248 ; Brit. Med., Jour., 1875, ii, 769. 



1? 

overflowing, stood practically empty. In Halle/ 6 Volk- 
mann was operating in an extremely unhealthy hospital 
in small, overcrowded wards, with the toilet rooms open- 
ing directly into them and a large drain running directly 
underneath. It was so bad that it had been condemned 
to demolition. After his introduction of the antiseptic 
method in 1872, no single patient suffering from com- 
pound fracture in which conservative treatment was 
attained had died either from the fracture or from a 
necessary amputation, nor was there a single death from 
secondary hemorrhage or gangrene. No case of blood 
poisoning had occurred for a year and a half, though 60 
amputations had been done. Hospital gangrene had 
entirely disappeared and erysipelas was extremely rare 
and mild. 

Perhaps, however, the most extraordinary success was 
obtained by Lister 27 in his own wards in Glasgow. Lis- 
ter was professor of surgery in Glasgow from March, 
1865, till the autumn of 1869, but in that brief period 
he introduced measures that were absolutely revolution- 
ary. The Eoyal Hospital in Glasgow was overcrowded, 
and in some parts of the building the conditions were 
so frightful that the wards had to be entirely shut up 
for a time. Lister's own account of this is interesting. 
He says : 

"A crisis of this kind occurred rather more than two years 
ago in the other male accident ward on the ground floor, sepa- 
rated from mine merely by a passage twelve feet .broad, where 
the mortality became so excessive as to lead, not only to clos- 
ing the ward, but to an investigation into the cause of the evil, 
which was presumed to be some foul drain. An excavation 
made with this view disclosed a state of things which seemed 
to explain sufficiently the unhealthiness that had so long 
remained a mystery. A few inches below the surface of the 
ground, on a level with the floors of the two lowest male acci- 
dent wards, with only the basement area, four feet wide, inter- 
vening, was found the uppermost tier of a multitude of coffins, 
which had been placed there at the time of the cholera epi- 
demic of 1849, the corpses having undergone so little change in 
the interval that the clothes they had on at the time of their 
hurried burial were plainly distinguishable. The wonder now 
was, not that these wards on the ground floor had been 
unhealthy, but that they had not been absolutely pestilential. 
Yet at the very time when this shocking disclosure was being 
made, I was able to state, in an address which I delivered to 

26. Lister, ii, 250 ; Brit. Med. Jour.. 1875, ii, 769. 

27. Lister, ii, 124 ; Lancet, 1870, i, 4. 40. 



18 

the meeting of the British Medical Association in Dublin 28 , 
that during the previous nine months, in which the antiseptic 
system bad been fairly in operation in my wards, not a single 
case of pyemia [blood poisoning], erysipelas, or hospital gan- 
grene had occurred in them ; and this, be it remembered, not 
only in the presence of conditions likely to be pernicious, but 
at a time when the unhealthiness of other parts of the same 
building was attracting the serious and anxious attention of 
the managers. Supposing it justifiable to institute an experi- 
ment on such a subject, it would be hardly possible to devise 
one more conclusive. 

Having discovered this monstrous evil, the managers at once 
did all in their power to correct it. . . . But besides having 
along one of its sides the place of sepulture above alluded to, 
one end of the building is coterminous with the old cathedral 
churchyard, ... in which the system of "pit burial" of 
paupers has hitherto prevailed. I saw one of the pits some 
time since. . . . The pit, which was standing open for the 
reception of the next corpse, emitted a horrid stench on the 
removal of some loose boards from its mouth. Its walls were 
formed on three sides of coffins piled one upon another in four 
tiers, with the lateral interstices between them filled with 
human bones, the coffins reaching up to within a few inches of 
the surface of the ground. This was in a place immediately 
adjoining the patients' airing ground, and a few yards only 
from the windows of the surgical wards! And the pit which I 
inspected seems to have been only one of many similar recep- 
tacles, for the Lancet of September 25 contains a statement, 
copied from one of the Glasgow newspapers, that "the Dean of 
Guild is said to have computed that five thousand bodies were 
lying in pits, holding eighty each, in a state of decomposition, 
around the infirmary." 

When to all this is added the fact that the large fever 
hospital was separated from the surgical hospital by only 
eight feet, that Lister's hospital of nearly 600 beds was 
cramped in area and almost always full to overflowing, 
and that he was operating, it might almost be said, in a 
charnal house, yet that those wards were continuously 
and conspicuously healthy and enjoyed for "three years 
immunity from the ordinary evils of surgical hospitals 
under circumstances which but for the antiseptic system 
were specially calculated to produce them," 29 we stand 
convinced by such a huge unintentional experiment on 
man himself. 

Were not results such as these sufficient to justify the 
experiments on animals as related by Lister himself and 

28. Lister, ii, 45. 

29. Lister, ii. 126 ; Lancet, 1870, i, 4, 40. 



19 

here quoted, by which such blessed relief has been 
brought to mankind? 

What was seen in Glasgow has occurred all over the 
world. The surgical revolution of the last thirty years 
is the most momentous in the entire history of surgery. 
In every science — chemistry,- engineering, botany, 
physics, electricity— the era of precise experiments has 
been the era when enormous and constant progress has 
been made. Medicine is no exception. We have closely 
studied disease by various observational methods, and 
clinical observation for two thousand years had slowly 
advanced our knowledge up to a certain point. Then 
experimental research, which employed methods of pre- 
cision, varying conditions at will, noting the different 
results, and multiplying the experiments at will instead 
of waiting, it might even be years, until Nature's second 
experiment occurred, began its work; and in the past 
thirty years experimental research has produced a more 
fruitful harvest of good to animals and to mankind than 
the clinical observation during thirty preceding cen- 
turies. 

But we are far from having attained perfection. In 
medicine and in surgery many problems of disease and 
death are still awaiting solution and can only be solved 
by the experimental method. A number of organs in 
the body are as yet inaccessible and' others have func- 
tions of which we know little or nothing. Many opera- 
tions ought to be bettered in method and in results. 
The causes of many diseases, such as cancer, scarlet fever, 
measles, whooping-cough, etc., are as yet unknown. To 
dispel all this ignorance and discover a cure for all these 
and other diseases is the earnest wish of wise and 
humane experimenters the world over. Shall the com- 
munity aid these humane life-saving efforts, or shall 
they by restrictive legislation call a halt and let death 
slay our fellow creatures and especially our dear chil- 
dren ? The answer is clear. It will never be other than 
an emphatic no to the latter cruel course. 

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